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  1. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-10/trocar_injury_final.pdf
    January 01, 2022 - Spotlight Spotlight Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong Source and Credits • This presentation is based on the October 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33826/psn-pdf
    February 01, 2017 - In Conversation With… Amy C. Edmondson, PhD, AM February 1, 2017 In Conversation With… Amy C. Edmondson, PhD, AM. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-amy-c-edmondson-phd-am Editor's note: Dr. Edmondson is professor of Leadership and Management at Harvard Business School. Her la…
  3. psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
    July 08, 2022 - SPOTLIGHT CASE Patient Safety Events Involving Opioid Dose Stacking Citation Text: Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Cita…
  4. psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insulin-therapy
    July 01, 2008 - Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy Citation Text: Newton B, Seitz R. Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…
  5. psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
    October 28, 2020 - Hospital-Acquired Diabetic Ketoacidosis. Citation Text: Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar Bi…
  6. psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
    January 29, 2021 - An Incomplete Anesthesia History Leads to Adverse Outcomes Citation Text: Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866578/psn-pdf
    August 28, 2024 - Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy August 28, 2024 Newton B, Seitz R. Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insul…
  8. psnet.ahrq.gov/perspective/conversation-kaveh-shojania-md
    February 26, 2025 - In Conversation With… Kaveh Shojania, MD November 1, 2015  Citation Text: In Conversation With… Kaveh Shojania, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation For…
  9. psnet.ahrq.gov/web-mm/forgotten-turn
    August 01, 2018 - SPOTLIGHT CASE The Forgotten Turn Citation Text: Barbour S. The Forgotten Turn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49721/psn-pdf
    December 01, 2014 - Ebola: Are We Ready? December 1, 2014 Barsuk JH, Barnard C. Ebola: Are We Ready? PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/ebola-are-we-ready The Case A 28-year-old man, well-appearing but pale, walked into the emergency department (ED) on a Wednesday afternoon at 3 PM complaining of nausea, vomiting,…
  11. psnet.ahrq.gov/perspective/conversation-eric-thomas-about-zero-harm-striving-reduce-preventable-harms-point
    September 24, 2024 - Patients understand that healthcare is incredibly complex.
  12. psnet.ahrq.gov/perspective/conversation-withsir-liam-donaldson-md-msc
    May 01, 2007 - The big breakthrough in airline safety was made when the field came to understand systems causation and
  13. psnet.ahrq.gov/perspective/conversation-withjoseph-britto-md
    February 01, 2007 - and the other focuses on improving physicians' skills in metacognition, the ability to monitor and understand
  14. psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress
    May 01, 2007 - The big breakthrough in airline safety was made when the field came to understand systems causation and
  15. psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
    February 01, 2007 - and the other focuses on improving physicians' skills in metacognition, the ability to monitor and understand
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49682/psn-pdf
    April 01, 2013 - From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case April 1, 2013 Newman-Toker DE. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premat…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60268/psn-pdf
    April 29, 2020 - Complications of ECMO During Transport April 29, 2020 Broman M. Complications of ECMO During Transport. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/complications-ecmo-during-transport The Case A 54-year-old woman with end-stage chronic obstructive pulmonary disease (COPD) was admitted with acute on chro…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49714/psn-pdf
    August 21, 2014 - Pitfalls in Diagnosing Necrotizing Fasciitis August 21, 2014 Goh T, Goh LG. Pitfalls in Diagnosing Necrotizing Fasciitis. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/pitfalls-diagnosing-necrotizing-fasciitis Case Objectives State the epidemiology of necrotizing fasciitis. Appreciate the high mortality a…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72614/psn-pdf
    March 01, 2021 - Rehearsing Team Care for Relatively Rare Obstetric Emergencies Leads to Improved Outcomes Originally published on December 22, 2020 Last updated on December 23, 2020 https://psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads- improved-outcomes Summary Multidisciplinary tea…
  20. psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
    April 27, 2022 - Annual Perspective Annual Perspective: Topics in Medication Safety March 31, 2022  View more articles from the same authors. Citation Text: Harris IB, Dowell P, Mossburg SE. Annual Perspective: Topics in Medication Safety. PSNet [internet]. Rockville (MD): Ag…

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